Provider Demographics
NPI:1104809425
Name:CUSACK, JAMES C (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:C
Last Name:CUSACK
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Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:YAW 7B
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-724-4043
Practice Address - Fax:617-724-3895
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
MA74063208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ11385OtherBCBS MA
MA0117781Medicaid
MA074063OtherTUFTS HEALTH PLAN
MA0117781Medicaid
E93300Medicare UPIN